Anxiety Disorders

Clinical Description

Anxiety disorders refers to a group of disorders that share features of excessive fear / anxiety and the related behavioral and physical disturbances with associated impairment in functioning or subjective distress.

Types:

• Phobias: characterized by irrational and excessive fear of objects/ public situations
• Panic disorder: characterized by recurrent spontaneous panic attacks, subsequent fear of another attack and maladaptive compensatory behaviours.
• Generalized anxiety disorder: excessive worry for six months or more about actual circumstances/ events

Signs and Symptoms

• Feeling tense, uncontrollable anxiety and worry
• Associated physical health symptoms e.g., heart palpitations, Sweating, chest pains, difficulty breathing, poor sleep, restlessness, feeling dizzy, lightheadedness or faint

Investigations

• Exclude comorbid mental health disorders such as depression and alcohol and drug use
• Elicit psychosocial stressors from patients as well as guardians
• Perform a physical examination to rule out other causes of anxiety such as thyrotoxicosis, asthma, etc.

Non-pharmacological

• Explain anxiety to patient especially the link between physical and psychological

Signs and Symptoms

• Give good health advice such as reducing or stopping substance use, good diet, exercise etc.
• Educate on relaxation methods such as deep breathing exercises during panic attack and muscle relaxation techniques
• The mainstay or first line treatment of anxiety disorders is psychotherapy such as exposure and systematic desensitization or cognitive behavioral therapy.

Pharmacological

• If symptoms are severe or psychotherapy hasn’t been effective, prescribe antidepressants in conjunction with the psychotherapy.
• 1st line: Give Fluoxetine 20 – 60 mg
• 2nd line: Give Amitriptyline 50-150mg nocte
• Avoid the use of diazepam and benzodiazepines except as short course medications (should not exceed 14 days)
• Propanolol (20 – 40mg) PRN may be used for short term symptomatic relief of excessive anxiety symptoms.

Red flags

For referral/admission

• If there is significant comorbid physical illness
• The symptoms are interfering with activities of daily living
• The patient is suicidal with no significant psychosocial support at home

Follow-up

• Once symptoms resolve, continue treatment for 6 months and consider stopping thereafter
• Assess for substance use and other psychosocial stressors.